My new book, "Health, Medicine and Justice: Designing a fair and equitable healthcare system", is out and and widely available!
Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Tuesday, December 29, 2009

.The New Year is a common time to rethink, make resolutions, and in various ways commit to leading a better life. We can do this as individuals and as a society. As far as health is concerned, our individual decisions can and do make a big difference in our health outcomes, and it behooves us to learn as much as we can and to be able to distinguish what is information based in evidence from what is opinion, anecdote, or just plain wrong. As a society we can do a lot better in terms of improving health, only one component of which is improving health care. We can, and must, improve access (both financial and geographic) to health care, improve the quality of care and the use of evidence-based (rather than profit-influenced) practices, and the use of cost-benefit ratios to maximize the value per dollar. Maybe we are moving a little in that direction; I will continue to comment on a number of areas surrounding health reform and health care.

One thing that can help us in thinking about ourselves and our societies are the thoughts of others. Epigrams, quotations, can and often do, oversimplify complex ideas, but they can be powerful and pungent. I have frequently used them; on the left side of this blog is a quotation from FDR that I find particularly significant. So, for the New Year, I thought I would provide some of my “favorite” quotations, some more well-known than others. I will also supply the authors, although not attached to the quotations; you can know or guess or look them up, but it can make a difference; a statement by someone who knows about an area can be more powerful than when the same statement comes from one who does not.

My last entry addressed, in part, bigotry, and the attempts of some people to have their beliefs determine the actions of everyone. This is common and recurrent, and does not “get better with time”. Much of Texas’ Hill Country was settled by Germans, a high percentage of whom were Freethinkers. They stood, among other things, against slavery; Confederate troops raided towns like Comfort, TX, killing many and driving others to Mexico. Some years ago a monument commemorating the Freethinker settlers who established the town was proposed for Comfort, but it didn’t happen. The people, conventional “believers”, even descendants of those settlers, found Freethinking too much like “atheism” for them. Of course, people who emigrate, who move to new lands, are different from both those who stay behind. They are bolder, more adventuresome and more independent. They are also, sometimes disappointingly, different from their descendants who are more settled, themselves the “stay behinders”. Many of our “Founding Fathers” were people who were Freethinkers, Deists, and believers in less orthodox approaches to religion. Often they were condemned in their time, but that time was the Enlightenment, when it was believed (wrongly as it turns out) that time would bring increased knowledge of science and the world, and that would leader to broader, not more narrow, thinking. The thoughts of a few:

"I Have Sworn Upon the Altar of God eternal hostility against every form of tyranny over the mind of man."

"Independence is my happiness, and I view things as they are, without regard to place or person; my country is the world, and my religion is to do good."

“It is now no more that toleration is spoken of, as if it was by indulgence of one class of people, that another enjoyed the exercise of their inherent natural rights.”

Not only FDR commented on the inequity of distribution; others also chose to identify what areas, including the determinants of health, might be a better place to spend our money.

"Every gun that is made, every warship that is launched, every rocket that is fired signifies, in the final sense, a theft from those who are hungry and are not fed, from those who are cold and are not clothed."

In a specifically health-related vein,

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

And a few more about our society, government, shadow government and rights:

“We the people are the rightful masters of both Congress and the courts, not to overthrow the Constitution but to overthrow the men who pervert the Constitution.”

"Our only hope today lies in our ability to recapture the revolutionary spiritand go out into a sometimes hostile world declaring eternal hostility to poverty, racism, and militarism.”

"Indeed, I think that people want peace so much that one of these daysgovernments had better get out of their way and let them have it."

And ones I will probably use soon:

"The war on privilege will never end. Its next great campaign will be against the privileges of the underprivileged."

“The potential for the disastrous rise of misplaced power exists and will persist. We must never let the weight of this combination endanger our liberties or democratic processes."

Wednesday, December 23, 2009

.The New York Times, in a December 22, 2009 editorial, calls the Senate bill “well worth passing” (A Bill Well Worth Passing), and says that it is “worthy of support from lawmakers who care about health care reform.” Whether it is worthy of support by the American people is another question entirely. The Times says that there is “…a lot to like in this bill”, and this is certainly true, as there are many parts of it, that include funding for many good programs. Some of the issues that I have written about in the past, such as primary care extension services and funding for primary care education (“Title VII”) are included in the bill. That makes me happy, and I think that they should be good for the health care of the American people.

A proposal that would expand graduate medical education funded by Medicare by 15,000 slots did not pass, which also makes me happy. Through aggressively supported by the Association of American Medical Colleges (AAMC), it has been opposed by family medicine organizations because the expansion would have been willy-nilly, not giving preference to or even a guaranteed base of funding for primary care. While it is true that there are needs for new physicians in areas other than in primary care, any bill that does not absolutely guarantee primary care slots will result in hospitals allocating them to those specialties that make the most money for the hospitals – certainly not primary care. Moreover, the key flaw of counting all students entering 3-year internal medicine residencies as primary care, despite, as I have discussed (recently November 17, 2009 Primary Care’s Image: A Problem?, October 14, 2009 "War on Specialists?": Wall St. Journal defends the status quo!, October 8, 2009"Uncomplicated" Primary Care?), the fact that the vast majority of them will enter subspecialty fellowship training. There is an excellent Op-Ed on December 23, 2009, addressing this issue in the Times, "Doctors no one needs", by Shannon Brownlee and David Goodman.

What, of course, is less good (or, as we might say, “bad”) is that 1) it doesn’t cover everyone; 2) it will save some money, maybe, but only a small portion of what might be done by a public option, not to mention a single-payer plan; 3) it will make the insurance companies even richer; 4) it will not guarantee affordable health care for Americans. We have already discussed this (December 6, 2009 Health Care Needs Should Guide Health Reform). It has even eliminated the buy-in to Medicare for people over 55. The core problems with the bill are detailed in the letter to the Senators by the leadership of the Physicians for a National Health Program (http://www.pnhp.org/news/2009/december/pro-single-payer-physicians-call-for-defeat-of-senate-health-bill).

But, as the Times notes in its front-page article on the bill (Democrats Face Challenge in Merging Health Bills by Robert Pear and David M. Herzenhorn), “Democrats were grappling Monday with deep internal divisions over abortion, the issue that most complicates their drive to merge the Senate and House bills and send final legislation to President Obama.” And this is indeed the part of the Senate bill, and in the House bill’s Stupak amendment, that gives free rein to the bigots who feel, literally, that it is their God-given right to apply their moral compass to the most important life decisions of the rest of us. In trying to garner the votes of marginal Democrats (like Ben Nelson in the Senate), the Congress has bowed to the efforts of the Catholic bishops to try to not only control the lives of their own believers, but those not of their religion as well. Make no mistake about this. As much as opponents say that they are opposing abortion, what they are actually doing is choosing to make the decisions about it for other people. All of those people who are affected are women, and most of those making the decision – including all bishops – are men.

Trying to reach a compromise (New York Times, Negotiating to 60 Votes, Compromise by Compromise, by Robert Pear, December 20, 2009), the Senate came up with nonsense. “In what they described as an effort to reduce the demand for abortion, Democrats would provide money to help pregnant teenagers and new mothers so that they could stay in high school and attend college. The federal government would provide $25 million a year for a ‘pregnancy assistance fund.’ The money could be used for ‘maternity and baby clothing, baby food, baby furniture and similar items,’ the proposal says.” If they weren’t politicians, these people would be described as, using the technical term, “lunatics”.

If you really want to “reduce the demand for abortion”, the first step, the necessary step, the sine qua non, is to reduce unwanted pregnancies. Amazing idea! How would we do that? Well, one way would be to tell people, convince people, cajole people, pray for people, and bribe people not to have sex, or not have sex with people to whom they are not married, or not have sex when they are not explicitly trying to have a baby. This is, incredibly enough, a very popular idea and strategy. I say “incredibly” because there is no evidence that it works and no reason to think that it might. For all of human history people have had sex, and the people with the strongest urge to do so are just the young people that we are trying to convince not to (ironically, the potency industry for old men, whom nature has decided do not need to have a desire or ability to have sex, is enormous!).

There is compelling evidence that every program designed to keep young people from having sex is a complete, utter, and absolute failure. Indeed, an unending line of ministers and politicians who preach and pontificate about the issue are having sex outside of their marriages, and proving by their behavior the vapidity of their words. It is of no importance to people outside of their immediate families whether they apologize or feel bad. What is important to the rest of us is that, if they don’t have the common decency to stop being politicians and trying to make policy that affects us all, that they abstain from voting on any issue with any sexually-related dimension.

On the other hand, there are much more effective methods for “reducing the demand for abortion”. They are two: widespread, comprehensive and truthful sex education, and widespread, freely available contraception. Unfortunately, I see no support for these measures in the current bills or in the complete blather coming from the mouths of the hypocrites above..

Friday, December 18, 2009

.On November 8, 2009, the New York Times began its 98th “Neediest Cases” campaign, to raise funds for charities that help New Yorkers who are in real financial hardship. This year, however, the results of the New York Times / CBS News Poll published in the Times on December 14, 2009 as “Poll reveals trauma of joblessness in US” by Michael Luo and Megan Thee-Brenan, document a much more widespread problem, across the US. In addition to the very disturbing data presented, the article, and even more the video clips available on line, put a face on these numbers, and the face is that not only of those in chronic poverty, unemployment and homelessness (who, it must absolutely be remembered, are those who are suffering the greatest negative effects of this “recession”), but of a more traditional working-and-middle class group. Fear of falling out of their social class, whether formerly upper-middle, middle, or working class, is a major concern documented in this poll and discussed on Michael Luo’s Economix blog on the same day.

Some of the data revealed by the poll:· 60% have taken money from savings and retirement accounts for daily expenses· 53% have borrowed money from family and friends· 46% feel embarrassed or ashamed about being out of work

Since this blog is often about medicine, some medically-related data:69% are more stressed, 55% have trouble sleeping, and 48% have experienced emotional or mental health issues like anxiety or depression.

And they will find it more difficult to receive help for these problems, since:54% have cut back on doctor’s visits and medical treatments, and47% are currently without some form of health care coverage.

The Times article says that “Americans struggling with job loss say unemployment has created a crisis in their lives and is exacting a crushing financial and emotional toll.” That seems correct, although not ‘right’, a word I almost used.

It is difficult to not find the contrast with the articles on the huge banks (JP Morgan, Bank of America, Citigroup, Wells Fargo) that are paying back the government’s TARP loans (e.g., “Wells Fargo to repay US, a coda to the bailout era”,New York Times December 15), to free them from the onerous burden of government regulation, such as limits on the outrageous salaries and bonuses that they can pay themselves, or the requirement that they actually loan money to credit-worthy businesses (especially small businesses) and individuals. For the bankers, I guess, the recession is over; the payback, in the word used in the article’s title, is a “coda” (“something coming after or at the end”, from the Latin “cauda”, tail). For those small business and individuals, as well as for the unemployed described in the poll, it is obviously not. And, if the bankers don’t feel secure enough to lend out money, why should they? They had to borrow all that money (“raise capital”) to pay off TARP, and to pay their executives. Sorry there’s none left to loan to you, to keep your business afloat and a few more workers off the unemployment line. (Of course, since the Clinton-era “welfare reform” we no longer have to watch folks on “relief lines”. There are none, because there is no relief.)

David Brooks’ Op-Ed column on December 15, 2009, “Obama’s Christian realism”, suggests that the president, more than his predecessors, has a moral framework that frankly includes “good and evil”. Focusing mainly on the President’s war policy, as enunciated in his West Point and Oslo (Peace prize!) speeches, Brooks essentially calls him a “cold-war liberal”, a label that Mr. Obama may not embrace. But certainly the President’s characterization of the bankers described above, who are not lending money, as “fat cats”, does suggest a good/evil belief system, and reinforces the sense that what we are seeing today is a frank real-world enactment of those old 19th-and-20th century pictures of evil greedy bankers, bosses, and capitalists trodding the working people under their feet. And if they, the bankers, or their apologists and flaks, want to take offense at the “class war” picture, it is their own fault, entirely; the situation, both the initial financial crisis and their current greed in the face of human suffering, is completely of their own making. (Of course, it always has been; the ruling class never complains about class war when they are not only winning, but completely unopposed. They raise the specter, however, when the least challenge to their hegemony is evident.)

Unfortunately, President Obama’s moral judgments do not seem to affect his administration’s policies, which have, molded by the Rubins and Summerses and Geithners, been unabashedly (ok, occasionally slightly abashedly, but certainly pretty completely) based on the critical nature of the success of Wall St., a far from universal opinion. For some data that supports an alternative opinion, the New Economics Foundation, a UK think tank, has a new publication, “A Bit Rich”, in which they look at the economic contribution of different jobs relative to the amount people are paid (h/t Alex Scott-Samuel, on the “Spirit of 1848” listserve). They discovered that hospital cleaners, because they prevent the spread of infection and preserve the health of the public, produce more than 10 times the value of their pay. Bankers earning over £500,000 a year (about $800,000) destroy (based on the effects of the recession on society) about £7 of value for every £1 they create.

So are the bankers evil? Maybe you have to ask the President, or David Brooks, or maybe you have your own opinion. Maybe they are just following their nature, like sharks. The question, however, is much more relevant when looking at members of Congress, especially Senators. The same folks who gave us the Bush-era $4 trillion in tax cuts for the wealthiest Americans, and, in the health arena, a Medicare drug benefit program that was forbidden from negotiating rates with pharmaceutical companies on behalf of consumers, are at it again. They have opposed every effort to rein in the excesses of the bankers (including a proposal to limit credit card interest rates to “only” 18% -- is there any rational human being who cannot identify higher rates as pure usury?), or to extend health care benefits to Americans, who, like those studied by the Times/CBS poll, are unemployed, or the even greater group who are still working but who cannot afford or whose employers do not offer health insurance, or those who have health insurance and find out when they get sick how little it covers.

Fortunately they are now in the minority, which has helped getting some kind of health reform passed in the House. The Senate, however, is a different story; compounding its constitutionally-based unrepresentative nature (remember how the “Gang of Six” Senators formulating the Finance Committee bill represented less than 3% of the US population?*), it has rules (not constitutionally mandated) requiring “super-majorities” of 60% to end filibusters. This has allowed the group of 40 Republicans – plus Joe Lieberman – to prevent single payer from being discussed, to remove the public option from consideration, and now to remove the possibility of people over 55 from buying into Medicare. Kansas Senator Sam Brownback, asked if he will vote for funds to support the troops in the middle east, says “No. I don’t want health care.” They talk about fiscal responsibility, but remember these are the same folks who pushed the enormously expensive tax cuts for the wealthy and restrictions on the Medicare drug plan mentioned above, but have treated single payer, which would not only cover everyone but save LOTS of money, as anathema.

So maybe they are hypocrites. Or maybe they are corrupt, in the thrall of the big corporations, including pharmaceutical and insurance companies, who make big contributions to them. Or, maybe, they are the ones who are evil. After all, the bankers – and insurance company and pharmaceutical company executives – (if you want to buy Milton Friedman economics) are supposed to follow their greed. Congresspeople and Senators, on the other hand, are supposed to work for the interests of the rest of us, and help, through regulation, to protect us from the power of the banks and big corporations.

But who do they actually work for? I’m not sure I want to know the answer.

*The six states that they represent rank 30, 36, 40, 44, 48, and 50 in population!

Monday, December 14, 2009

Five years ago, on November 29, 2004, the Canadian Broadcasting Corporation (CBC) program "The Greatest Canadian" revealed the winner of that designation. According to Wikipedia, this "was not decided by a simple popular poll, but was instead chosen through a two-step voting process. On October 17, 2004 the CBC aired the first part of The Greatest Canadian television series. In it, the bottom 40 of the top 50 "greatest" choices were revealed, in order of popularity, determined by polls conducted by E-mail, Web site, telephone, and letter. To prevent bias during the second round of voting, the top ten nominees were presented alphabetically rather than by order of first round popularity. This second vote was accompanied by a series of documentaries, where 10 Canadian celebrities acting as advocates each presented their case for The Greatest Canadian.” The winner was not a Canadian prime minister, or sports figure, or show business celebrity, or even inventor (like Alexander Graham Bell – did you know he was Canadian?). It was Tommy Douglas.

Who? If you’re American, you probably haven’t heard of him, but that would likely be true of most of the top 10 (except Bell and Wayne Gretzky, who were nos. 9 and 10, and maybe Pierre Trudeau). Douglas, who died in 1986, was a prime minister of the western prairie province of Saskatchewan in the 1940s and 50s. In 1961 he became the first national leader of the New Democratic Party, a post he held for 10 years. I’m sure he was a fine leader in many ways, but what won him this honor was the fact that he was the father of the Canadian national healthcare system, called Medicare. First introduced in Saskatchewan in 1962, the program became federal in 1966 with passage of the Canada Health Act, and was fully implemented by 1971.

Canadian Medicare is a “single-payer” system, such as that advocated by many, including myself, for the United States. It is actually administered by each of the country’s 13 provinces, with much of the funding coming from the federal government through a match. While there are some differences in the coverage in the different provinces, they all must meet five principles: they must be publicly administered, comprehensive, universal, portable (i.e., residents of one province must be covered in other provinces), and accessible. In Canada, doctors and other medical practitioners (mostly in private practice) provide services and submit the bill to the “single payer”, the provincial health ministry, and are then reimbursed at rates annually negotiated between the ministry and the medical associations. Hospitals are provided funding on an annual basis (a “global” fee) rather than fee-for-service, and importantly capital budgets are separate from operating budgets, so that a hospital cannot scrimp on patient care services in order, for example, to build a new building or buy an expensive piece of equipment. Everyone is covered. Everyone can get care. Administrative costs, for both providers and government, are kept down because there is only one payer. Costs for healthcare continue to rise, but at a much slower pace than in the US (see figure).

Are there complaints? Sure. There will always be complaints from people in any system not built specifically around them and their individual needs. Are waiting times sometimes longer than in the US? For elective procedures they might be, provided that you are a person who has excellent health insurance in the US. If you are a person without, or with poor, health insurance you might never get elective surgery in the US. And the waits in Canada, most recently, are certainly not excessive...4 weeks for elective surgery, 3 for an MRI scan. We hear stories of Canadians coming to the US for health care, and undoubtedly there are well-to-do people in Canada who do not wish to wait in line with everyone else (a common characteristic of many of the well-to-do), so come to the US. A 2002 study published in Health Affairs by Katz, et. al. (“Phantoms in the snow: Canadians’ use of health care services in the United States”) revealed, among other data, that in a survey of 18,000 Canadians only 90 had received any health care in the US in the last year and of those, only 20 had gone seeking it (hey, Canadians do go to Florida in the winter and get sick!). And there are many more uninsured Americans who cross the border in search of health care; so many that the Canadian provinces have now put photographs on their Medicare cards so that US citizens cannot borrow them from Canadians.

The system works quite well. Most Canadians (over 80%) are very satisfied with it, and a very small % would wish to trade it for a non-system like that in the US. But this is not what is going to happen with US health reform. Despite the support of nearly 100 representatives for Rep. John Conyers’ “Medicare for All” bill, and the work done in the House by him and others such as Anthony Weiner and Dennis Kucinich, it was not part of the House proposal. And a similar proposal from Sen. Bernie Sanders will likely not be voted on in the Senate. Instead, we are getting sausage – liberally spiced with financial input from the health insurance industry.

Most Americans do not know who Tommy Douglas is, but Canadians do. And they believe that spearheading their single-payer universal health system earns him the title of “Greatest Canadian”. I don’t see any of the leaders of the current effort to “craft” health reform in the US earning a similar honor..

Thursday, December 10, 2009

.On December 9 and 10, 2009, a massive “C.A.R.E.” clinic, sponsored by the National Association of Free Health Clinics occurred in Bartle Hall, the huge Convention Center in Kansas City. On the first day alone, with temperatures well below 20 degrees and the roads covered with ice from the snow that fell the night before, as many as 1,000 people showed up to receive health care from 1,600 volunteers, including 100 doctors, dentists, and nurse practitioners. It may end up seeing more people than similar events previous held in Houston, New Orleans and Little Rock. There is excellent coverage of the event in an article by Alan Bavley in the Kansas City Star, accompanied online by photos and videos by the Star’s Todd Feeback.

The purpose of these clinics is, of course, to provide some care to the people who attend – often the only care they have gotten in years. People were diagnosed and sometimes treated for acute conditions, such as pneumonia, or diagnosed with chronic diseases such as high blood pressure, high cholesterol, and diabetes. Indeed, most often they were really re-diagnosed; they knew they had these conditions but had been unable to afford medications or medical care. But another, even more important purpose, as Sherri Wood, Director of the Kansas City Free Clinic, says in the video, is to “put a face on the uninsured”. They are not only, or mostly, homeless, alcoholic, completely down-and-out, or even mostly unemployed. Rather, they are employed in low-wage jobs (not infrequently 2 or 3 jobs!) that do not offer health insurance, or they are employed part-time so that their employer does not have to buy their insurance. They are people, American people, our friends and families and neighbors. And they could be us; most Americans are a layoff away from uninsurance, and not too many paychecks away from dire financial straits and even homelessness.

The excellent accompanying editorial in the Star is titled “Massive free clinic at Bartle Hall a great event, but reform is still needed”. The editorial, along with the story, includes interviews with and comments from people who came for services (“Making three dollars an hour plus tips I can’t afford to see a doctor. When you have a house payment and your bills, it’s hard.”), but it also clearly states that “Although impressive, the free clinic clearly is no substitute for reliable medical care”. Yes, indeed. Or rather, No, indeed, it is certainly not. “Charity isn’t a good substitute for justice”, as I have quoted Jonathan Kozol before.

The Star editorial goes further, making the point that I have often made that a solution to the health care problem includes producing more primary care physicians. “Too many medical school graduates gravitate to high-paying specialties partly to pay off burdensome student loans.” We must, it says, “…encourage physicians to take up primary care.” It is appropriately critical of the fact that “The reform bills in Congress contain few incentives to set things right…Expanding access won’t work unless we start now to increase the supply of primary care physicians.”

So the problem is clear. And the solution is clear. Universal health coverage. Based on the principle that we need to ensure that people receive care, not that for profit companies make money. It has been figured out by every first-world (and some not quite first world) countries. It is not tricky, difficult, or even expensive (certainly not compared to what we are spending now). Not that it will happen, or happen easily, as the “debate” in Congress is currently demonstrating.

Maybe some of the opponents of real, meaningful, comprehensive health reform are just mean, evil, selfish people. I don’t rule that out. But more likely they are “blinkered”, like a horse, looking at only one aspect of the problem, such as the Kansas legislator who is proposing that our state refuse to participate in any health reform plan passed by Congress. (I am trying really hard to believe that this is his/her issue, being like the blind men of India with the elephant, not that s/he is mean, evil and selfish.) Plus the campaign contributions from the insurance companies and drug companies and health providers who are doing just fine, thank you, under the current system of literally leaving people out in the cold, help sway their beliefs.

It is time for the leaders of our country to stop compromising on a core need of our people, and ensure that everyone has access to quality health care. And they can do it in a responsible and cost effective manner through a single payer system, although there are other alternatives. The Star editorial says “A compassionate and cost-effective system would provide every American with a medical ‘home’ from which to receive preventive and needed care.”

I hope that most of our congressmen and other leaders are compassionate, and am certain that they wish to be cost-effective. But they need to abandon pandering to big contributors and keep this core value front and center: Quality health care for all..

Sunday, December 6, 2009

.As the debate over health care reform proceeds in the Senate, and in the nation, it is important to take stock of the key assumptions of those planning the changes. The Democrats have chosen to combine increased regulation and requirements for insurance companies with economic incentives, in an effort to cover more people and reduce skyrocketing costs. The Republicans have chosen to combine a core opposition to any proposal originating from the Administration or the Democratic leadership (articulated by New Hampshire Republican, and almost-Obama-cabinet-appointee, Judd Gregg) with cynical attempts to portray themselves as the defenders of currently-insured Americans by opposing cuts while criticizing the proposal for not saving enough money. The classic here is John McCain, who campaigned on a platform of quite draconian cuts in Medicare, screaming that the much more modest cuts in the Democratic proposal will, essentially, kill old people.

While the Democratic proposal does resemble an effort to patch the chinks in a leaky old house as winter approaches, leaving lots of holes and at cost greater than fixing the whole thing, the Republican scare tactics should be seen as what they are. Across the board cuts in Medicare would be a bad idea, as are almost all across-the-board cuts in any organization, but cuts which reduce the over- and unnecessary use of expensive tests and procedures, while increasing access to primary care, would save a lot of money. To be sure, the doctors and hospitals who provide those tests and procedures would take a financial hit, but it is unlikely to lead them to food stamps. A colleague who is in the health care field, but not a physician, told me that he had been at a meeting in which a Canadian doctor talked about the structure of their payment system, which pays subspecialists less than they make here, and observed that such change would be opposed by the specialists who would not welcome their income being reduced from, say, $600,000 to $400,000. What is there to say? Life is tough? It is hard to see the American people, worried about their jobs and future, increasingly (as I have recently discussed) on food stamps, fighting to prevent such losses. And, more important, I am sure that we will find doctors in those subspecialties who are willing to work for the $400,000.

The bigger problem with the Democratic proposal is that most of its solutions are based on creating business and economic incentives to try to get insurers to do the right thing, or at least a little more right and a little less evil. This is, I suppose, good insofar as it goes, and seems to be convincing even progressive economists such as Paul Krugman (“Reform or else”, New York Times December 4, 2009). But the idea of patching the house of health care using economics is intrinsically flawed, when the model should be based on social justice, morality, and doing the right thing for our nation and our people. Sophisticated businesses, whether Wall St. banks or health insurance companies, will always find ways to “game the system”, to find profit by reducing service, no matter how the economic incentives are structured (although surely they can be structured better than they are now). Even organizations that are intended to meet the health needs of the underserved can, because of the way incentives are structured, find that they can do better (or even simply survive) by caring for some needy in preference to others.

A case in point is one of our local Federally-Qualified Health Centers (FQHCs), also known as Community Health Centers (CHCs). I discussed these entities nearly a year ago, on December 30, 2008 (Community Health Centers, and more recently on September 3, 2009, Public/Private funding: We’re all in this together). These clinics are financially supported by the federal government largely because, in return for caring for the poor and meeting other federal service and reporting requirements, they receive cost-based reimbursement for Medicare and Medicaid patients, leading to Medicaid payments that are usually several times that paid to private doctors. They also usually receive a federal grant that helps support care provided to the uninsured. However, that money is never enough, and the additional funds from Medicaid and Medicare help subsidize that care for the uninsured.

One branch of the local FQHC located in northeast Wyandotte County, KS, where I live, served a desperately poor neighborhood. Indeed, most of the people are not on Medicare (because they are too young) or on Medicaid (because, while many are unemployed and others work for low wages at businesses that do not provide health insurance, either they are not families with young children or, if they are, they are often undocumented and ineligible). So the clinic was financially unable to support itself, and has solved its problem by moving to another part of the county, where the percentage of poor people with Medicaid is much higher. Still poor, to be sure, and in need of providers, but a good business move for the FQHC.

The problem, of course, is those people living in their old community. They did not go away, become more prosperous, or become more likely to be insured. They just lost their only source of health care. It’s hard to completely blame the FQHC, for all other providers left that community long ago, although the FQHC was specifically designed to fill these gaps. It is possible, and popular, to blame the “illegals” who make up much of this abandoned population, but while this works for propaganda, it is not so smart in reality. These people are here, and absent access to primary and preventive care they will continue to show up in emergency rooms to receive care for advanced disease that could have been treated more cost-effectively.*

Fortunately for this community, an independent, non-federally supported, safety net clinic (disclaimer: I am on its Board) has opened a small satellite in the basement of a church in that community. In doing so, it is not employing a traditional business plan; it is going where the need is, rather than where it can expect to make money. This will be a good thing for the people of that community, but it is no solution to the health care crisis, and cannot be expected to be replicated everywhere as a means of patching those chinks in our system. Not only does it depend upon funding from private foundations to exist, it depends upon enormous “in kind” contributions from its health care providers, doctors and dentists and nurses, who all receive the same wage as every other worker in the clinic, currently $12/hour.

But it could work on a national basis; not the part about doctors and dentists earning $12 an hour (we’re not talking here about $400,000 instead of $600,000!), but rather a national plan for a system that is predicated not on profit but on caring for people. A health care system which did not discriminate among people, but ensured that providers caring for everyone could survive and make a living, so that there would not be big parts of our population left out. Like a single-payer plan. Like Medicare for All.

Our system is upside down. Every other first world country has a health system built upon the idea that everyone is entitled to access to health care. Financial incentives to providers and insurers may work to fill some gaps. Ours uses financial incentives to provide care to a majority of our population, but it is a shrinking percent and even for them the coverage is decreasing and the cost is rising, and volunteerism and sacrifice are relied upon to fill the holes.

A health system for our country should start with ensuring access to high-quality health care for all our people. As I have discussed before, it may actually save money, but the reason to do it is that it is the right thing to do.

*This is not to mention that they work and pay taxes – often payroll, but certainly sales taxes – for low wages. What happens when they really leave – see “Arizona” – is there aren’t enough people to do these jobs, and aren’t enough people to rent housing – causing a major negative financial ripple effect..

Wednesday, December 2, 2009

.The New York Times article “Food stamp use soars across US, and stigma fades” by Jason DeParle and Robert Gebeloff (November 29, 2009) details not only the dramatic increase in the number of people on food stamps across the country, but the fact that many people who would never have thought of themselves as candidates for “welfare” now (sometimes ruefully) avail themselves of this “Supplemental Nutrition Assistance Program” (SNAP). In two telling county-by-county maps we are shown, first, which counties have had the greatest increase in recipients of “nutritional assistance” (as food stamps are now called), and then which have the greatest percent of recipients.

The map showing percent increase, calls our attention to the West, Florida, and the North Central States, with Utah, Nevada, Arizona, California, Idaho, Washington, Wisconsin and Florida all darkly colored. As shown on the second map, these are mostly states that previously had relatively low percents of people on food stamps, and are even are now just catching up; they are still below the areas with the heaviest proportions – the Texas-Mexico border; the Appalachian strip through West Virginia, Kentucky, Tennessee, Arkansas, and Missouri; the Mississippi Delta; anywhere there is an Indian reservation. The South as a whole looks bad, but always has, because of the combination of low union penetration resulting in low wages, many people employed in marginal agriculture, and terrible social services. The interactive map feature is “cool” – you can hover over any county in the US and find out what percent of its population is on food stamps, and what the change (almost always “increase”) has been. The result is that “There are 239 counties in the United States where at least a quarter of the population receives food stamps…”, and do, nationally, one in four children.

While there are a number of smaller counties that have almost half (49%) of their population on food stamps, the two with the highest percents among counties with over a half-million people are Bronx County, NY, and Hidalgo County, TX, tied at 29%. Ironically, the last time Hidalgo County (county seat=McAllen) hit the national news it was when it was revealed, in Atul Gawande’s New Yorker piece, the “Cost Conundrum” (discussed in my post ‘Medicare Costs: ‘All Politics are Local’” on June 11, 2009), that it was the region that had the highest Medicare cost per person in the country.

This is pretty sad. It is sad that so many people in this country have to swallow their pride and take food stamps. “’It’s time for us to face up to the fact that in this country of plenty, there are hungry people,’” says SNAP’s director. “The program’s growing reach can be seen in a corner of southwestern Ohio where red state politics reign and blue-collar workers have often called food stamps a sign of laziness,” the Times tells us. But, of course, it is not “laziness” when it is you.

It is hard to think of this without thinking of the multi-billion dollar bailouts given to the bankers and financiers so that they could continue to give themselves huge bonuses. While it may be true that these companies were too big to fail, there is no reason that they had to use our tax money to pay their employees, each of whom is only a person, just like the people who are increasingly in need of food stamps. We are told that some statistics, such as that the rate of job losses are slowing, indicate that “we” as a country may be on our way out of the recession, but that still means that there are fewer people working each month than there were the month before; I don’t think such statistics mean as much to the more of “we” who are out of work each month as the statistics showing the increase in folks on food stamps. I don’t think that it makes the six people looking for each available job feel much better.

I am still marveling at the juxtaposition of the food stamp story with an advertisement in the program for a concern I recently went to. Under the photo of a sultry and glamorous beauty in a gown leaning against an elegant bar with a glass in one hand, the text says: “The glass is half full…of champagne. The more than 97 percent of KC consumers who spend $27,000 , or more, per month on personal luxuries subscribe to one necessity every month – KC Magazine.” I am sorry that it is not online and I can’t reproduce it. I had to read that several times to be sure I hadn’t read it wrong – it is, after all, a tortured sentence. Yes, $27,000. A month. That’s a lot of money. Over half the average annual household income in our region. But they’re not talking about income. They’re talking about luxuries. $27,000 a month on luxuries. $324,000 a year. Or more. In Kansas City, not even New York or LA. I am amazed at the audacity of it.

Paul Krugman’s recent column (“The Jobs Imperative”) calls for a new Works Progress Administration in which the government would directly create jobs. I don’t think this is going to happen because the Obama administration is not bold enough, and has never shown such boldness. It completely kowtowed to the financial sector, and is afraid to take on the right-wing bloviators in Congress who say they represent the American people when in fact all they want to do is to further screw the American people. Most of all it won’t happen because the Congress is owned by wealthy contributors, and doesn’t really work for the American people. It is a very sad situation, but at least we can be confident that few Congressmen, even when they retire, will require food stamps.

We as Americans seem, on so many fronts, to be unable to put ourselves in the position of others, even as we move toward that position. This is true in the area of reproductive rights, where younger women do not realize that if they don’t fight for it now, abortion could not be available when they need it (Sheryl Gay Stolberg, In Support of Abortion, It’s Personal vs. Political, New York Times November 29, 2009). It is true when we fail to realize that without a universal health insurance program, our access to health care can disappear with our jobs. It is also, clearly, true with regard to our basic human needs, such as food. In the Times story, the formerly-employed food stamp recipients of southeastern Ohio say “I always thought it was people trying to milk the system. But we just felt like we really needed the help right now,” and “I always thought people on public assistance were lazy, but it helps me know I can feed my kids.” So would “those people”. Maybe we need to start thinking about how what happens to some of us can happen to us all.

German Pastor Martin Niemöller wrote:“First they came for the communists, and I did not speak out—because I was not a communist;Then they came for the trade unionists, and I did not speak out—because I was not a trade unionist;Then they came for the Jews, and I did not speak out—because I was not a Jew;Then they came for me—and there was no one left to speak out for me.”

Most of us would agree with the woman in the Times article who said “I like to have a nice decent meal for dinner.” It’s not too much to ask that this be the goal of our national policies, and let the financiers and those people who are spending $27,000 a month – or more! – on “personal luxuries fend for themselves. .